Alcohol and Parenting: The Effects of Maternal Heavy Drinking - October 1998

2. Literature Review

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The abuse of alcohol is a pervasive and pernicious problem. It is the most or second most prevalent psychiatric disorder according to general epidemiological surveys (Helzer & Pryzbeck, l988; Kessler et al., l994). Affected individuals, however, seldom receive treatment; estimates suggest that only 5 to 20% ever receive problem focused care (Emrick, l989; Moore et al., l989). This is a troubling omission given the cost and consequences of the disorder. In the United States, yearly direct cost estimates are 98.6 billion dollars (Rice, l993), while in Canada one estimate was 5.2 billion dollars (Eliany, l989). The health ramifications of alcohol related disorders are enormous, argued by some as representing the third major health expense, the single major reason for trauma emergency room visits, and the basis for a fourth to a third of all general hospital admissions (Pattison & Kaufman, l982; Gordis, l989; Johnson et al., l995; Umbricht-Schneiter et al., l99l). These statistics reflect the role of abusive drinking on cardiomyopathy, brain damage, cancer, liver disease, mental illness, and social mayhem including rapes, murders, assault, suicide, family violence and accidents. For example, heavy drinking at the time of the act is present in approximately half of all rapes, murders, and assaults (Murdoch et al., l990). In addition there are substantial costs related to absenteeism and decreased job performance. Significantly, other than children affected by prenatal exposure to alcohol, estimated to occur in from 0.5 to 3 births per l,000 (Iom, l996), the effect of abusive drinking on the development of children is seldom considered when detailing the consequences of alcohol abuse. This is likely a glaring omission as statistically it has been estimated that l in 8 children have an alcoholic parent, and there is substantial evidence of the effect of a family history of alcohol on the development of children. Children of alcoholics (COA's) have universally high rates of accidents, mental illness admissions, substance abuse, general hospital admissions with longer stays, and total higher health costs (Children of Alcoholics Foundation, l990). It is thus understandable that recent years have seen a great deal of interest in the study and treatment of children of alcoholics.

2.1 Children of Alcoholics

The literature on children of alcoholics (COA's) has been extensively reviewed (Sher, l99l; Galanter, l99l; Windle & Searles, l990). Two general foci are apparent in this literature. First, there is a focus on the characteristics of these offspring, particularly sons of male alcoholics (Pihl et al., l990), in an attempt to delineate risk factors for the further development of alcohol and behaviour problems. The second focus is on the treatment of children of alcoholics, and there is a massive clinical literature which dates to the beginning of this century. Driven by the adult children of alcoholics movement, these individuals are often seen and see themselves as victims of parental behaviours (Stark, l987). For many, being the child of an alcoholic is viewed as representing the existence of problems per se (Black, l982). Various authors have suggested that these individuals are often characterized by low self-esteem, anxiety, guilt, anger and rage, impulsivity, inconsistency, humorlessness, constricted emotions, hypervigilance, stress related illnesses, a history of victimization, physical and/or sexual abuse, and substance abuse (Cermak, l988; Woititz, l984; Brown, l988; McKearn, l988). Unfortunately, as the focus of treatment is on the affected individual, comparatively little work is directed toward understanding the putatively responsible parenting behaviours. Sher & Mothersead (l99l, page 166) conclude that "although it is known that COA's are at risk for a number of negative outcomes, the various pathways to each of these outcomes are still not well understood and it is not clear what variables are most important to target."

Overwhelmingly, the bulk of the experimental literature on COA's is descriptive of the problems these individuals display and is often integrated into high risk research paradigms. The intent is not to determine which parental variables led to the characteristics of interest but rather how the characteristics of interest make the individual vulnerable to developing drug and other psychological problems. In fact, a good portion of this literature assumes a genetic model and thus parenting practices per se are not even considered. A particular focus in these studies are sons of male alcoholics, as, until recently, these individuals have been seen to be at a much higher risk for the development of alcohol problems than daughters or offspring of female alcoholics. Numerous reviews exist on this specific population (Pihl et al., l990; Peterson & Pihl l994; Tarter, et al., l985; Windle & Searles, l990). The literature does illustrate how sons of male alcoholics do show distinctive behavioural, cognitive, electrophysiological, biochemical and alcohol responses. Behavioural dysregulation, disciplinary problems, impulsiveness, and negative affectivity are most frequently described. These individuals often reflect histories of rebellion, conduct disorder, and antisociality which has led some to argue that antisocial tendency rather than family alcoholism is the important risk factor (Hesselbrock & Hesselbrock, l992). Personality characteristics which are consistent with this above profile are tendencies to be "high novelty seekers" (Finn et al., l992), reflect under control (Harden & Pihl, l994; Sher et al., l99l), and to be less altruistic and more irresponsible (Sher et al., l99l). Cognitively, these individuals have been shown to reflect mild to moderate impairments in what has been called executive functions encompassing abstraction, planning, and problem solving. Problems with language, attentional and memory processing, psychomotor integration, visual perceptual analysis, and learning have been noted as well (Drejer et al., l985; Knop et al., l985; Peterson et al., l992; Schaeffer et al., l984; Tarter et al., l989). There are a few studies (Harden & Pihl, l994; Tarter et al., l990) where parental pathology is controlled, which have been taken to suggest the importance of a non parenting predisposing factor. However this result may represent only a small segment of COA's and only explain the vulnerability in a genetic vulnerability-stress model.

A number of researchers (Chassin et al., l993; Pihl & Peterson, l992; Sher & Trull, l994; Tarter et al., l993) have suggested a form of vulnerability model for COA's where the individual characteristics of irritability/impulsivity interact with poor parental care to increase risk for conduct disorder and academic failure as well as subsequent drug abuse. Much evidence supports the conclusion of a problematic family environment. Economic and marital instability (West & Prinz, l987), irregular caretaking (Sher, l99l), increased violence and abuse (Kumpfer & Bays, l995) and generally little cohesion, high conflict and poor communication (Moos & Moos, l984) have been reported in families with an alcoholic parent/parents. Unfortunately, the culpable parenting practices have received less attention. Suggested candidates are inconsistent and unpredictable parenting (Windle, l996), poor parental monitoring (Dishion & Loeber, l985), low parental nurturance and warmth (Brook et al., l990), harsh discipline (Patterson, l986), and a greater tolerance for deviancy (Johnson & Pandina, l99l).

2.2 Consequences of Maternal Alcohol Consumption on Offspring

As is apparent in the preceding paragraphs, research on the impact of parental alcohol consumption on offspring development has concentrated on paternal drinking. A literature search on maternal alcohol consumption using psychology and medicine publication data banks showed that the vast majority of studies focus on at least one of the following topics: consequences of parental drinking (mothers and fathers confounded) on offspring development, psychopathology, or behaviour (Barber & Crisp, l994; Bensley, Spieker, & McMahon, l994; Brook et al., l996; Roosa et al., l996); parental drinking and its degree of risk on offspring substance use/abuse during preadolescence and adolescence (Hops et al., l996; Quine & Stephenson, l990); fetal alcohol syndrome, and more generally, impact of maternal consumption of alcohol and other drugs during pregnancy on a child's physical, psychological, and intellectual development (Little et al., l989; Mayes, l995; O'Connor, Sigman, & Kasari, l993; Steinhausen, l995; Steinhausen, Nestler, & Huth, l982); and the consequences of maternal drinking on adult offspring (Hill et al., l988; Marcus, l986; Schuckit, l984). Very little effort has been made to isolate the impact of maternal drinking on offspring, independent of alcohol use and abuse during pregnancy. Most studies do not differentiate between prenatal, perinatal, and postnatal maternal alcohol consumption. Research addressing drinking and drinking problems in mothers has remained a relatively neglected area.

Two studies which did control for alcohol consumption during pregnancy and focused on maternal drinking were completed by Hill and colleagues. Hill & Muka (l996) tried to determine the prevalence of psychiatric disorders among children who had been selected based on their maternal family history of alcoholism, although more than half of these children also had an alcoholic father. High-risk children came from families with multigenerational alcoholism in first- and/or second-degree female relatives, while low-risk (control) children had no first- or second-degree relative with an alcohol dependence. These authors found that children under age l3 with an alcoholic mother and a non-alcoholic father were 3 to 5 times more likely to exhibit a psychopathology (affective disorder, anxiety disorder, oppositional/conduct disorder, Attention Deficit Hyperactivity Disorder), compared with age-matched controls (low-risk children). The same comparison was used between high-risk children with and without prenatal exposure to alcohol, but only one significant finding came out of the comparison: children of mothers who drank during pregnancy were more susceptible to be diagnosed with conduct disorder. The facts that reports of abstinence or alcohol consumption during pregnancy were reported several years later by the alcoholic mother, that degree of alcoholism (or of alcohol use and abuse) currently and during pregnancy were not assessed, and that paternal drinking was confounded must temper conclusions. In a second study, Hill, Muka, Steinhauer, & Locke (l995) used the same sample of subjects to look at specific amplitude decrements of an event-related potential, which is an electrical response of the brain to a brief sensory stimulus. The wave form after 300 milliseconds is referred to as the P300 component, and has been seen as a possible neuropsychological risk marker for the development of alcoholism, as associated with particular sensory and cognitive aspects of information processing, and as under genetic control. The study found that the children from families with multigenerational alcoholism in first- and/or second-degree female relatives displayed decrements in P300 amplitude in both auditory and visual modalities, compared with controls. The visual modality paradigm discriminated risk groups best for male children, and the auditory paradigm discriminated risk groups best for female children. These findings led the authors to conclude that the P300 component of the ERP indexes a developmental delay in children of alcoholic mothers and demonstrates the transmission of alcoholism risk from mothers to children. However, alcoholism in the father was controlled only for female children's data analyses. Other evidence suggests that children of alcoholic mothers are more affected than children of alcoholic fathers, displaying more negative experience (Velleman & Orford, 1990) and a greater likelihood to develop psychopathology (Heinz, 1990). Moser and Jacob (1997) studied father alcoholic, mother alcoholic, and both parent alcoholic families and found that both parent and mother alcoholic only families presented the most impaired parent-child interactions. These mothers reflected a lower level of positive interactions and a higher level of negative interactions toward their own children.

Studies where maternal and paternal drinking, other drug use, and prenatal exposure are confounded nonetheless provide suggestions as to maternal effects and possible mediators. Heavy maternal alcohol and other drug consumption has been shown to be related to more insecurity in children at age 1 year (O'Conner et al., 1987), to teacher ratings of overactivity in school (Bell & Cohen, 1981), to less responsible child rearing (Tarter et al., 1993), to less parental agreement in parent-child interactions (Whipple et al., 1995), and to both internalizing and externalizing behavioural disposition in the children (Moss et al., 1995). The amount of alcohol consumed (Johnson & Pandina, 1991), the mother's personality attributes (Brook et al., 1996), the presence of co-morbid psychopathology including cognitive impairment (Sher et al., 1991) , and socioeconomic status (Ellis et al., 1997) are seen as possible mediators of this relationship.

2.3 Parenting Variables of Possible Import

In contrast to the available literature on maternal drinking and parenting, there is a massive fund of knowledge concerning parental variables predictive of antisocial behaviour and behaviour problems. A few studies will be mentioned simply to illustrate potential variables of import. Social disadvantage (low socioeconomic status) is a parenting variable that has been linked in studies seemingly from time immemorial to antisocial behaviour. That not fitting the basic societal norm leads to non normative behaviour is, although problematic, not hard to understand. Heavy drinking does correlate negatively with SES requiring the consideration of this variable in all analyses. The relationship to parenting is however more complex as, for example, it has been shown that social class interacts with interpersonal security so that individuals low in both tend to use adult centered approaches to children involving coersive power (Booth et al., l99l). In another related study (Pedersen & Yoerger, l995), early arrest and adolescent physical trauma was predicted from type of parental discipline, the monitoring of children, changes in family structure, and the amount of unsupervised time spent outside the home. Further, low parental academic achievement has been associated with ineffective discipline practices and subsequent antisocial behaviour and academic difficulties in offspring (DeBaryshe et al., l993).

When SES is controlled, children from single mothers, stepfathers or multiple transition families, particularly the latter, are seen at risk for antisociality (Capaldi & Patterson, l996). Alcoholic families have been shown to have higher frequencies of divorce (Von Knorring, l99l). A recent study (Dépelteau et al., l998) found that sons of paternal alcoholics from intact families were more disruptive at ages 7 to l0. Another factor requiring consideration is maternal depression. Fifty percent of women in the National Comorbidity Study are seen as displaying additional psychopathology, many depression (Kessler et al., 1997). The negative effect of this condition on offspring's mental health is well detailed. Recently, Weissman et al. (l997), in a prospective study, showed that these individuals were at risk for anxiety, mood, and alcohol dependence disorders.

Poor parental discipline either of an abusive/neglectful nature or involving poor monitoring practices has been related to the development of antisociality (Dishion et al., l99l). Strauss & Cantor (l994) have shown that children who experienced corporal punishment in adolescence, with SES controlled, had increased risk for a series of psychopathological, behavioural, and drug abuse problems. Widom (l993) found that abused/neglected women, but not men, followed prospectively, developed subsequent alcohol abuse problems. Generally, parents of externalizing boys have been shown to be more punative and less nutrative (Florsheim et al., l996), and more harsh and prone to use physical discipline (Stoolmiller et al., l997). These various aspects of parenting style which are predictive of subsequent problems may in fact be more important than parental use of alcohol or other drugs. Johnson & Pandina (l99l) for example suggest that parental alcohol use is actually secondary to parenting style in determining problematic outcomes.

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